Younger patients with chronic limb threatening ischemia face more frequent amputations

Revascularisation of Chronic Limb Threatening Ischaemia in Patients with no Pedal Arteries Leads to Lower Midterm Limb Salvage

OBJECTIVE

Chronic limb threatening ischaemia (CLTI) involving the infragenicular arteries is treated by distal angioplasty or pedal bypass; however, this is not always possible, due to chronically occluded pedal arteries (no patent pedal artery, N-PPA). This pattern represents a hurdle to successful revascularisation, which must be limited to the proximal arteries. The aim of the study was to analyse the outcome of patients with CLTI and N-PPA after a proximal revascularisation.

METHODS

All patients with CLTI submitted to revascularisation in a single centre (2019 - 2020) were analysed. All angiograms were reviewed to identify N-PPA, defined as total obstruction of all pedal arteries. Revascularisation was performed with proximal surgical, endovascular, and hybrid procedures. Early and midterm survival, wound healing, limb salvage, and patency rates were compared between N-PPA and patients with one or more patent pedal artery (PPA).

RESULTS

Two hundred and eighteen procedures were performed. One hundred and forty of 218 (64.2%) patients were male, mean age 73.2 ± 10.6 years. The procedure was surgical in 64/218 (29.4%) cases, endovascular in 138/218 (63.3%), and hybrid in 16/218 (7.3%). N-PPA was present in 60/218 (27.5%) cases. Eleven of 60 (18.3%) cases were treated surgically, 43/60 (71.7%) by endovascular and 6/60 (10%) by hybrid procedures. Technical success was similar in the two groups (N-PPA 85% vs. PPA 82.3%, p = .42). At a mean follow up of 24.5 ± 10.2 months, survival (N-PPA 93.7 ± 3.5% vs. PPA 95.3 ± 2.1%, p = .22) and primary patency (N-PPA 53.1 ± 8.1% vs. PPA 55.2 ± 5%, p = .56) were similar. Limb salvage was significantly lower in N-PPA patients (N-PPA 71.4 ± 6.6% vs. PPA 81.5 ± 3.4%, p = .042); N-PPA was an independent predictor of major amputation (hazard ratio [HR] 2.02, 1.07 - 3.82, p = .038) together with age > 73 years (HR 2.32, 1.17 - 4.57, p = .012) and haemodialysis (2.84, 1.48 - 5.43, p = .002).

CONCLUSION

N-PPA is not uncommon in patients with CLTI. This condition does not hamper technical success, primary patency, and midterm survival; however, midterm limb salvage is significantly lower than in patients with PPA. This should be considered in the decision making process.

Age-dependent outcome of first-line endovascular and surgical revascularization strategies in chronic limb-threatening ischemia

OBJECTIVE

Chronic limb-threatening ischemia (CLTI) has a high mortality and amputation risk even after revascularization. Due to an ageing population the incidence of peripheral arterial disease is rising. However, the current age distribution in patients with CLTI and the impact of age on outcome remains unclear. For this reason we performed an age-dependent analysis of mortality, morbidity, and amputation-free survival after open surgical revascularization (OSR) and endovascular revascularization therapy (ERT) with identification of risk factors for mortality. Standardized mortality ratios (SMR) were calculated, comparing observed deaths in the study population to expected deaths based on age and gender specific mortality rates of the overall Dutch population.

METHODS

Patients revascularized for a first episode of CLTI between 2013 and 2018 were included in this multicenter retrospective cohort study. The cohort was divided in two treatment groups (OSR and ERT) who were each stratified in three age groups: early age group <65 years (G1), middle age group 65-74 years (G2) and elderly age group ≥75 years (G3).

RESULTS

During the study period 274 limbs (43.9%) were treated with OSR and 350 limbs (56.1%) with ERT. The young population (G1) is only a small part of the whole CLTI population, namely for OSR 22% and ERT 18%. The risk profile of the early age group was characterized by male sex and smoking, while the elderly age group was characterized by poor arterial runoff, tissue loss, hypertension, hypercholesterolemia, chronic kidney disease, history of heart disease, COPD and cerebrovascular disease. One year amputation rates were similar between the age groups. However, significantly higher one year mortality rates were observed in patients ≥75 years in comparison to the low mortality rates in patients <75 years. (OSR: G3 19.8% vs G2 7.1% and G1 6.7%, P = .006; ERT: G3 30.7 vs G2 12.7% and G1 7.8%, P = .001). The SMR in this elderly group equaled 3.72 after OSR and 4.04 after ERT. Independent risk factors for mortality after OSR were age, hazard ratio (HR) 1.03 (95% confidence interval (CI) 1.01-1.06; P = .006), preoperative hemoglobin level, HR 0.79 (95% CI 0.67-0.92; P = .003), tissue loss, HR 1.85; 95% CI 1.22-2.79; P = .004), cardiac history, HR 1.56 (95% CI 1.06-2.30; P = .024) and development of postoperative delirium, HR 2.75 (95% CI 1.61-4.71; P < .001) . After ERT we identified age, HR 1.06 (95% CI 1.04-1.08; P < .001), preoperative hemoglobin level, HR 0.75 (95% CI 0.65-0.87; P < .001), tissue loss, HR 1.71 (95% CI 1.15-2.53; P = .008), history of chronic obstructive pulmonary disease (COPD), HR 1.99 (95% CI 1.43-1.79; P < .001), history of cerebrovascular accident (CVA), HR 1.55 (95% CI 1.09-2.21; P = .015), the development of postoperative pneumonia, HR 2.27 (95% CI 1.24-4.16; P = .008), postoperative acute kidney injury (AKI), HR 2.42 (95% CI 1.29-4.54; P = .006) and postoperative CVA, HR 8.17 (95% CI 1.96-34.15; P = .004) as risk factors.

CONCLUSIONS

The current CLTI population consists mostly of elderly patients and only a small part is younger than 65 years. This shift in the population is important because increasing age is associated with considerable higher one year mortality rates regardless of the method of revascularization in patients with CLTI. The mortality rates in the elderly group are three to four times larger than expected in the general population. In relation to the high mortality of the elderly patient, we assume that interventions to prevent postoperative delirium and correct preoperative anemia may be warranted as they appear to be independent risk factors for mortality.